Traumatic Brain Injury Clinical Guidelines

Introduction

The momentum for evidence-based healthcare has been gaining ground rapidly, motivated by clinicians, and management concerned about quality, consistency, and costs of healthcare intervention. The use of Clinical Guidelines, based on standardised best practice, has been shown to be capable of supporting improvements in quality and consistency in healthcare and is considered one of the main ways that evidence-based medicine can be implemented. Clinical Practice Guidelines weres defined by Field and Lohr [1] as "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances".[1][2]

According to Woolf et al [3] Clinical Guidelines have become one of the foundations of efforts to improve healthcare and health care management. Methods of guideline development have progressed both in terms of process and necessary procedures, and the context for guideline development has changed, with the emergence of Guideline Clearinghouses and large scale guideline production organisations e.g National Institute for Health and Clinical Excellence (NICE). [3]

The brief video below shows the way they can be used in practice.

[4]

Purpose

Clinical guidelines provide recommendations on how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment, and longer-term management and are designed to support the decision-making processes in patient care. The content of a guideline is based on a systematic review of research literature and clinical evidence - the main source for evidence-based care. [5]

"The aim of clinical guidelines is to improve the quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay ut in the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways ,and inter-professional agreements". [6]

  • To describe appropriate care based on the best available scientific evidence and broad consensus
  • To reduce inappropriate variation in practice
  • To provide a more rational basis for referral
  • To provide a focus for continuing professional education
  • To promote efficient use of resources
  • To act as a focus for quality control, including audit
  • To highlight the shortcomings of existing literature and suggest appropriate future research. [5]

Limitations and Controversy

Clinical Guidelines can have their limitations and there can be controversy surrounding some recommendations within some guidelines. Not every patient or situation fits neatly into a guideline. Guidelines to not always cover every eventuality and each patient's circumstance needs to be taken into consideration when treatment is decided upon. Recommendations should be viewed as statements that inform the clinician, the patient and any other user, and not as rigid rules.

Research and resulting evidence-based recommendation in the acquired brain injury field impose great difficulties on best practice and clinical guideline development. According to “Rehabilitation following Brain Injury Guideline” the challenges for clinical guidelines in the management of traumatic brain injury include:

  • the marked heterogeneity with respect to the patient group, the intervention and setting, and to the outcomes that are relevant at each stage of recovery
  • the small numbers group, ethical considerations, due to many patients with traumatic brain injury lacking the mental capacity to give fully informed consent confounding the application of randomised controlled trial designs 
  • the ethical problem with randomisation of patients to ‘no treatment’ or even ‘standard’ care since the expanding body of evidence of the effectiveness of multidisciplinary rehabilitation in other conditions, particularly stroke, become available
  • the funding issues of long-term projects whilst length of time over which rehabilitation may have its effects (often months or years) is usually longer than any funded research.

Due to those limitations having a significant impact on the research design and quality, the guidelines also utilise a significant degree of expert opinion and existing consensus-based documents. 

Level of Evidence Type of Evidence  Grade of Recommendation
Ia Meta-analysis of randomised controlled trials (RCTs) A
Ib At least one RCT A
IIa At least one well-designed controlled study, but without randomisation B
IIb At least one well-designed quasi-experimental design B
III At least one non-experimental descriptive study (eg. comparative, correlation or case study) B
IV Expert committee reports, opinions and/or experience of respected authorities C

Table.1 Generally used classification of evidence and recommendations whilst developing clinical guideline 

Degrees of Recommendation
A At least one meta-analysis, systematic review or clinical trial classified as 1++ and directly applicable to the target population of the guideline; or a volume of scientific evidence composed of studies classified as 1+ and with great consistency among them 
B A volume of scientific evidence composed of studies classified as 2++, directly applicable to the target population of the guideline and showing great consistency between them; or scientific evidence extrapolated from studies classified as 1++ or 1+
C A volume of evidence composed of studies classified as 2+, directly applicable to the target population of the guideline and showing great consistency between them; or scientific evidence extrapolated from studies classified as 2++
D Scientific evidence level 3 or 4 or scientific evidence extrapolated from studies classified as 2+
Good Clinical Practice
Recommended practice, based on clinical experience and consensus of the group of experts 

Table. 2 Degrees of recommendation according to Scottish Intercollegiate Guidelines Network

Clinical guidelines are not always an exhaustive form of evidence-based practice. Other sources like Cochrane Collaboration or evidence database like PEDro are recommended in sourcing clinically valuable assessment and treatment approaches and organisational principles, especially in such heterogeneous population slike traumatic brain injury survivors. Therefore, synthesis of established guidelines’ knowledge with clinical findings about individuals with traumatic brain injury, and clinically reasoned judgment by the treating therapist clinician,is the most effective approach to the management of the individual with traumatic brain injury. 

Traumatic Brain Injury Clinical Guidelines

While the evidence base for traumatic brain injury management and rehabilitation is increasing, substantial gaps still remain with an ongoing need for more research to improve both service delivery and more importantly patient outcomes. Many of the Clinical Guidelines related to traumatic brain injury treatments are focused on medical management such as avoidance of secondary injury. Overall most guidelines during each phase of management recommend that all individuals with a traumatic brain injury should have access to specialised traumatic brain injury care.

Guidelines

Head Injury: Assessment and Early Management (2014)

Type: NICE Guideline

Publication Date: 2014

This guideline contains recommendations for the assessment and early management of head injury in children, young people and adults and is for healthcare professions, people with brain injury and their families.  “It promotes effective clinical assessment so that people receive the right care for the severity of their head injury, including referral directly to specialist care if needed.” The guideline includes recommendations on:

  • Pre-hospital assessment and advice, and immediate management at the scene
  • Assessment in the emergency department
  • Investigating clinically important brain injuries and injuries to the cervical spine
  • Information and support for families and carers
  • Transfer from hospital to a neuroscience unit
  • Admission and observation
  • Discharge and follow-up

The guideline demonstrates best practice in patient-centred care and key priorities for implementation in areas of transport to ha ospital, assessment in the emergency department, criteria for performing a CT Head Scan, investigating injuries to the cervical spine, discharge ,and follow-up.

Guidelines for the Management of Severe Traumatic Brain Injury (2016)

Type: International Brain Injury Guidelines by Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), AANS & CNS Joint Section of Neurotrauma and Critical Care. [7]

Publication Date: 2016

The guideline contains a set of evidence-based recommendations for acute medical and clinical care of adults with severe TBI to prevent complication and improve patients’ outcomes. It provides recommendations for treatment like hypothermia, decompressive craniectomy, use of anaesthetics or sedatives, but also prevention of medical complications like infections, seizures, deep vein thrombosis. The guideline informs local algorithms and care pathways development

Management of Concussion-mild Traumatic Brain Injury (2016)

Type: Clinical Guideline by the Department of Veterans Affairs and Department of Defense

Publication Date: 2016

The guideline document supports the critical decision points in the Management of Concussion/mild Traumatic Brain Injury (mTBI) and provides comprehensive evidence-based recommendations incorporating current information and practices for clinicians working with adults with TBI and concussion. The guideline is intended to improve patient outcomes including symptoms and functioning, adherence to treatment, recovery, well-being, and quality of life. The recommendations aim to minimize preventable complications and morbidity.

The guideline contains recommendations about diagnosis, assessment and treatment of symptoms including headache dizziness, balance problems, cognitive symptoms, fatigue, visual and hearing symptoms, sleep disturbance and pain.

Rehabilitation Following Acquired Brain Injury (2003)

Type: Guideline by the British Society of Rehabilitation Medicine (BSRM) and supported by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians (RCP). [8]

Publication Date: 2003

The guideline has been developed by multidisciplinary and multiagency experts in solving BSRM, RCP, charities working with people with acquired brain injury and individuals with ABI.  It provides a robust framework for the management of adults with ABI and provides standards of care from post-acute long-term care aiming to reduce morbidity, facilitate function restoration and community reintegration. The guideline provides sets of recommendations addressing the quality of life of patients living with ABI but also their relatives. 

With the “Head injury: assessment and early management” guideline the “Rehabilitation following acquired brain injury ” guideline provide a comprehensive framework for ABI management from pre-hospital to long-term care at clinical care and service provision level. 

The guideline provides recommendations regarding:

  • Principles and organisation of services
  • Approaches to rehabilitation
  • Carers and families
  • Early discharge and transition to rehabilitation services
  • Inpatient clinical care - preventing secondary complications in severe brain injury
  • Rehabilitation setting and transition phases
  • Rehabilitation interventions
  • Continuing care and support
  • The need for further research
  • Algorithm for early discharge into the community and referral to rehabilitation

Particularly relevant to physiotherapy services:

G1 Every patient with an acquired brain injury should have access to specialist neurological rehabilitation services:

  • covering all phases from acute management, through medium-term rehabilitation to long-term support 
  • for as long as required – which may be life-long. 

G11 Following acute ABI, patients should:

  • be transferred as soon as possible to a rehabilitation programme of appropriate intensity to meet their needs
  • receive as much therapy as they need, can be given and find tolerable
  • be given as many opportunities as possible to practise skills outside formal therapy Sessions

Rehabilitation

G12 After the post-acute phase, continued rehabilitation in the community should support a balance of activity based on the patient’s individual circumstances. This should move progressively from formal therapy to a guided and supported resumption of chosen activities over months or years.

G13 There should be recognition of the need for life-long contact to meet the changing clinical, social and psychological needs of patients and carers.

G19 There should be a single interdisciplinary patient record system in which all members of the team record their interventions. 

G23 Rehabilitation programmes should be developed in collaboration with family, carers or nursing staff to ensure that the programme is carried over into daily activities. 

Optimising Respiratory Function

G43 The patient’s respiratory function should be optimised through early mobilisation, positioning, advice on oxygen therapy and appropriate manual techniques as advised by a specialist interdisciplinary team.

G45 Patients with a tracheostomy should be reviewed at frequent intervals and a weaning programme instituted as soon as this is appropriate, to facilitate early decannulation.

G46 Tracheostomy care and weaning should be undertaken in accordance with the published guidelines.

G47 A designated interdisciplinary tracheostomy team including nurses, physiotherapists, and speech and language therapists should take responsibility for setting and reviewing parameters for weaning, effecting good tracheostomy procedures and maintaining care.

Positioning and Handling

G57 All team members handling patients should be taught safe and appropriate ways to handle patients. 

G58 A suitable moving/handling programme for each patient with limited mobility should be:

  • instituted through collaboration between physiotherapy and nursing staff within 48 hours of admission
  • applied consistently by all staff
  • reviewed and revised as the patient’s needs change.

G59 Patients unable to protect their pressure areas should:

  • have a clinical assessment for risk of pressure sores 
  • be provided with appropriate pressure-relieving equipment (mattress, cushion, etc) without delay 
  • have regular inspection of the skin area at risk to ensure that adequate protection is occurring 
  • have access to specialist advice from special seating teams, tissue viability specialists, etc.

Management of Spasticity and Prevention of Contractures

G60 Patients with spasticity should be assessed and treated by an interdisciplinary team with experience in the management of spasticity. 

G61 Patients with marked spasticity and/or contractures should have a coordinated plan for interdisciplinary management including:

  • elimination of simple causative or aggravating factors such as pain and infection
  • the use of specific treatment modalities such as serial plaster casts or removable splints if appropriate 
  • the use of antispasmodic drugs including botulinum toxin where appropriate.

Early Sitting and Standing

G63 Every brain-injured patient who remains unconscious or is unable to sit themselves up should have a graded programme to increase tolerance to sitting and standing. 

G64 Patients should be stood and sat by adequately skilled staff with appropriately supportive equipment.

Motor Function and Control

G100 A physiotherapist with neurological expertise should coordinate therapy to improve motor function for all patients with a brain injury. 

G101 Any of the current physical treatment approaches should be practised within a neurological framework to improve patient function but should also take account of associated orthopaedic or musculoskeletal injuries. 

G102 The programme should include a written plan, with illustrations where appropriate, to guide other members of the team in carrying over motor skills into other daily activities.

Supportive Seating and Standing

G103 Patients who are unable to maintain their own sitting balance should have:

  • timely provision of an appropriate wheelchair and suitable supportive seating package 
  • regular review to ensure continued suitability of the seating system as their needs change. 

G104 Patients with complex postural needs should be referred to a specialist interdisciplinary team who have expertise in specialist seating. 

G105 Patients who are unable to stand independently should be provided with a suitable standing aid if appropriate, and this provision should be continued into the community if still required at the time of transfer.

Aids and Orthoses

G106 Patients with mobility problems should be considered for appropriate walking or standing aids to improve stability (C) which may include an ankle-foot orthosis.

G107 If an orthosis is supplied it should be individually fitted.

Improving Motor Control

G108 When planning a programme to improve motor control, the following should be considered to improve motor control and general fitness:

  • treadmill training with partial body weight support as an adjunct to conventional therapy
  • strength training to improve motor control in targeted muscle groups 
  • gait re-education to improve walking ability
  • exercise training to promote cardiorespiratory fitness.

Optimising Performance in Daily Living Tasks

G141 All patients with difficulties in activities of daily living

  • should be assessed by an occupational therapist with expertise in brain injury 
  • should have an individual treatment programme that is aimed at maximising independence in areas of self-maintenance, productivity and leisure. 

G142 All daily living tasks should be practised in the most realistic and appropriate environment, with an opportunity to practise skills outside therapy sessions. 

G143 Social services should recognise that provision of ‘care’ for some patients with acquired brain injury may mean the supervision and practice of community living skills, rather than hands-on physical care. 

G144 Family and carers should be involved in establishing the most appropriate routines for activities of daily living which take account of their lifestyle and choices.

SIGN Guidance for Brain Injury Rehabilitation in Adults (2013)

Type: Guideline by Scottish Intercollegiate Guidelines Network (SIGN) [9]

Publication Date: March 2013

The guideline for healthcare professionals managing patients with brain injury across sectors (in primary, secondary, tertiary or independent health care or the voluntary sector) covering in detail the longer-term rehabilitation of adults (16 years of age and over) with brain injury following the post-acute stage. The guideline provides evidence for cognitive, communicative, emotional, behavioural and physical rehabilitation interventions as well as patient outcomes in relation to optimal models and settings of care, the benefits of discharge planning and the applicability of telemedicine. The information provided is relevant to individuals with brain injury and their families.

Physical Rehabilitation and Management Recommendations include:

  • Repetitive task-oriented activities are recommended for improving functional ability, such as sit-to-stand or fine motor control. Grade of recommendation B
  • Casts, splints and passive stretching may be considered in cases where contracture and deformity are progressive. Grade of recommendation C
  • Botulinum Neurotoxin Therapy (BoNT) may be considered to reduce tone and deformity in patients with focal spasticity. Grade of recommendation B
  • A full assessment of bladder and bowel function should be undertaken over a period of days following admission. The physical, cognitive and emotional function of the patient should be considered and the multidisciplinary team should be involved to plan an individualised approach. [null Additional good practice recommendation]

Service Delivery Recommendations include:

  • For optimal outcomes, higher intensity rehabilitation featuring early intervention should be delivered by specialist multidisciplinary teams. Grade of recommendation B
  • Community rehabilitation services for patients with brain injuries should include a wide range of disciplines working within a coordinated interdisciplinary model/framework and direct access to generic services through patient pathways. Additional good practice recommendation

Clinical Practice Guideline for Rehabilitation of Adults Moderate to Severe Traumatic Brain Injury

Type: Guideline by the Québec Institut national d'excellence en santé et en services sociaux (INESSS) and the Ontario Neurotrauma Foundation (ONF) [10]

Publication Date: September 2018

The guidelines were developed by a collaborative effort of researchers, clinicians, and policymakers from Ontario and Quebec with focus on community-based rehabilitation and end-users’ needs “including providing prioritisation of recommendations for implementation, implementation tools, indicators to measure uptake, system implications, and background rationale and evidence supporting the recommendation”. 

The clinical practice guideline contains recommendations related to the components of the optimal TBI rehabilitation system as well as components of assessment and rehabilitation of the sequelae of brain injury like:

Prolonged Disorders of Consciousness: National Clinical Guidelines (2015)

Type: Guideline by Royal College of Physicians (RCP) [11]

Publication Date: October 2015

The National Clinical Guideline contributing to clinical and ethical standards of treating and looking after patients with disorder of consciousness and prolonged disorder of consciousness. The guideline was developed by a panel of experts and provides the information for clinicians, other healthcare professionals, service providers and commissioners what constitutes be the practice and legal decisions making process tools. It helps decide where patients should be cared for, how to use the life-sustaining treatments appropriately, and provides principles of management at the end of life.

It contains the following sections:

  • Defining Criteria and Terminology
  • Assessment, Diagnosis, and Monitoring
  • Acute to Longer-Term Management
  • Ethical and Medico-Legal Issues
  • End-of-Life Issues
  • Service Organisation and Commissioning

The guideline advocates strong role of families in the care of patients with PDoC and emphasisez their need for access to information, training a,nd support.  ”Further systematic longitudinal data collection” and the development of a national register and dataset of cases with a disorder of consciousness and prolonged disorder of consciousness is championed.

Downloadable chapters include:

  • Prolonged Disorders of Consciousness - FULL National clinical guidelines
  • Annex 1a Evaluation of responses in patients emerging from MCS
  • Annex 1b Literature on prognosis for recovery
  • Annex 2a Full Formal Clinical Assessment
  • Annex 2b Minimum requirements for assessors of prolonged disorder of consciousness patients
  • Annex 2c Optimising conditions for response
  • Annex 2d Comparison of WHIM, CRS-R and SMART tools
  • Annex 2e Features for families and care staff to look for
  • Annex 2f Evaluation and record of diagnosis of VS or MCS
  • Annex 3a Clinical Management
  • Annex 4a Best interests checklist for patients with PDOC
  • Annex 4b Role of family and friends in medical decisions
  • Annex 4c Template for an Advance Decision to Refuse Treatment (ADRT)
  • Information for families about medical decisions

Early proactive management of patients with Disorders of Consciousness recommendations include:

The multidisciplinary goal-orientated programme of care should include a 24-hour programme of care including:

  • airway management, including tracheostomy care, management of secretions, ventilatory support if required
  • enteral nutrition and hydration per gastrostomy (or jejunostomy if gastric stasis or oesophageal reflux are problematic) – with adequate nutritional support to meet dietary requirements, including enhanced calorie intake in the case of a hyper-catabolic state
  • management of oral reflexes (eg bite reflex, teeth-grinding etc)
  • suitable bowel and bladder management programme
  • suitable precautions to avoid pressure ulceration, including risk assessment, special mattress etc
  • positioning/stretching to manage tone and avoid contractures,, maintain skin integrity
  • supportive seating to offer a range of positions and allow assessment in a sitting position
  • early discharge planning, including a formal meeting with the family (and/or other representatives) and healthcare commissioners, to discuss the place of care and to start to put in place the appropriate arrangements for funding (usually through an application for NHS Continuing Care).

Medium-term care in slow stream pathway should include the provision of:

  • an appropriate maintenance therapy programme to manage their physical disability
  • an appropriate environment to provide controlled stimulation and encouragement for interaction
  • ongoing monitoring of their level of responsiveness.

Long-Term Care

Long-term care should be provided in an appropriate setting and ensure the following:

  • management of physical disability, including maintenance therapy for tone/postural management (including management of spasticity and prevention of contractures/pressure sores etc), medical surveillance, etc.
  • enteral feed and tracheostomy management
  • appropriate stimulation and ongoing assessment of behavioural responses
  • support for families.

If the nursing home does not have its own therapy team, arrangements should be in place to provide a maintenance therapy programme through visits from the local community rehabilitation team or an alternative spot-purchasing arrangement.

Clinically-Assisted Nutrition and Hydration and Adults who Lack the Capacity to Consent (2018)

Type: Guideline by the British Medical Association, Royal College of Physicians (RCP) and General Medical Council (GMC) [12]

Publication Date: October 2018

The Prolonged Disorders of Consciousness guideline is closely related Guidance on clinically-assisted nutrition and hydration guideline published in 2018 by Royal College of Physicians (RCP) and British Medical Association (BMA) and General Medical Council (GMC). This guidance covers decisions to start, restart, continue, or stop CANH for adults in England and Wales who lack the capacity to make the decision for themselves. It includes information related to previously healthy patients sustaining a sudden brain injury, but also those with complex comorbidities and neurodegenerative comorbidities.

Key topics covered in the guideline include:

  • The Legal Context for decision-making
  • Who is the decision-maker, and who must be consulted?
  • Conscientious Objections
  • Clinical Assessments
  • Best Interests Assessments
  • Second opinions
  • Managing Disagreement and Uncertainty
  • Record-Keeping
  • Governance and Audit

Splinting for Prevention and Correction of Contractures in Adults with Neurological Dysfunction

Type: Practice Guideline by Royal College and Occupational Therapists (RCOT) and Association of Chartered Physiotherapists in Neurology (ACPIN) [13]  

Publication Date: 2015 

The guideline provides and evidence for clinical practice and decision-making process when providing splints for adults with neurological conditions, especially with TBI stroke and MS. It describes the roles and responsibilities of health professionals in the prevention and correction of contractures in patients who are at the risk of deformities. The guideline carefully weighs benefits and risks of the splinting process in individuals with upper motor neuron syndrome. It demonstrates factors for caution and when splinting should not be advised.

The guideline recommends splinting to be considered “not in isolation but as one part of a comprehensive goal-directed rehabilitation or management programme” and demonstrates systematic key steps for consideration when splinting adults with contractures. It supports the clinical reasoning of patient selection, recommends agreeing on an action plan prior to splinting, with MDT and patient and/or relatives and outcome measures for evaluation of the process. It does not give any practical tips with regards to manufacturing casts or splints. The online resource includes a Neurosplinting CPD session.

Spasticity in Adults: Management using Botulinum Toxin

Type: Guideline by Royal College of Physicians, British Society of Rehabilitation Medicine, The Chartered Society of Physiotherapy, Association of Chartered Physiotherapists in Neurology and the Royal College of Occupational Therapists [14]

Publication Date: March 2018

The guideline provides recommendations for treatment of spasticity with botulinum toxin (BoNT) in adults living with neurological conditions. It recommends the botulinum toxin treatment to be a part of a comprehensive goal-directed rehabilitation and management programme. The guideline highlight mainly upper and lower limb treatment, however some other use of botulinum toxin is mentioned like in neck or jaw muscles. It lines up common areas of intervention when using BoNT:

  • Pain Relief
  • Reduction of involuntary movements (i.e.: associated reactions, spasms)
  • Prevention of contractures and deformity
  • Passive Function (making it easier to care for the affected limb)
  • Active Function (using the affected limb)
  • Mobility

The guidelines demonstrate evidence for self-management, postural management, stretching, task practice, strength training, electrical stimulation and various pharmacological treatment in spasticity management before demonstrating the role of botulinum toxin in this process.

The guideline provides recommendations about prescribing, storing, administration as well as muscle selection, techniques of injection, evaluation of the treatment and post-injection management when treating neurological patients with BoNT. It also gives recommendations about service organisation.

Standards for Rehabilitation Services Mapped on to the National Service Framework for Long-Term Conditions

Type: Service standards by the British Society of Rehabilitation Medicine (BSRM) [15]

Publication Date: 2009

Specialist Neuro-rehabilitation Services: Providing for Patients with Complex Rehabilitation Needs

Type: Service Standards by the British Society of Rehabilitation Medicine (BSRM) [16]

Publication Date: 2009

The two documents define a clear set of guidelines and targets, mapped on to the NSF-LTC, for the planning and delivery of rehabilitation services in the United Kingdom. The documents define specialist rehabilitation, different complexity levels in neurological conditions, patient group categories and individual patient’s needs.

The documents provide recommendations for neurorehabilitation services; organization (including staffing ration and funding streams to enhance the patients’ outcomes) and functioning of clinical pathways and networks (eg trauma, stroke, neuroscience).

References

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  2. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20;318(7182):527-30.
  3. 3.0 3.1 Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implementation Science. 2012 Jul 4;7(1):61.
  4. NICE How to use NICE Pathways Available from: https://www.youtube.com/watch?v=NxFwWICaVSc (last accessed 18.10.2019)
  5. 5.0 5.1 Open Clinical. Clinical Practice Guidelines. Available from: http://www.openclinical.org/guidelines#refs (accessed 2 May 2017).
  6. Wollersheim H, Burgers J, Grol R. Clinical guidelines to improve patient care. Neth J Med. 2005 Jun;63(6):188-92.
  7. Carney N, Totten AM, O'reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM. Guidelines for the management of severe traumatic brain injury. Neurosurgery. 2017;80(1):6-15.
  8. Turner-Strokes L, editor. Rehabilitation following acquired brain injury: national clinical guidelines. Royal College of Physicians.
  9. Scottish Intercollegiate Guidelines Network (SIGN). Brain injury rehabilitation in adults. Edinburgh: SIGN; 2013. (SIGN publication no. 130). [March 2013]. Available from: http://www.sign.ac.uk (Accessed 15 September 2019)
  10. INESSS-ONF Guideline. Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe TBI. 2018. Available from: https://braininjuryguidelines.org/modtosevere/ (accessed 15 September 2019)
  11. Royal College of Physicians of London. Prolonged disorders of consciousness: national clinical guidelines. Royal College of Physicians. Available from: https://www.rcplondon.ac.uk/guidelines-policy/prolonged-disorders-consciousness-national-clinical-guidelines (accessed 15 September 2019)
  12. British Medical Association. Wade DT. Clinically Assisted Nutrition and Hydration. 2018. Available from: https://www.bma.org.uk/advice/employment/ethics/mental-capacity/clinically-assisted-nutrition-and-hydration/clinically-assisted-nutrition-and-hydration-canh-guidance (accessed 15 September 2019)
  13. College of Occupational Therapists, Association of Chartered Physiotherapists in Neurology. Splinting for the prevention and correction of contractures in adults with neurological dysfunction: practice guideline for occupational therapists and physiotherapists. College of Occupational Therapists Limited; 2015.
  14. Royal College of Physicians, British Society of Rehabilitation Medicine, The Chartered Society of Physiotherapy, Association of Chartered Physiotherapists in Neurology and the Royal College of Occupational Therapists. Spasticity in adults: management using botulinum toxin. National guidelines. London: RCP, 2018. Available from:https://www.bsrm.org.uk/downloads/spasticity-in-adultsfinal-version-published23-4-18.pdf (accessed 15 September 2019)
  15. Turner-Stokes L, Ward C. BSRM Standards for Rehabilitation Services, mapped on to the National Service Framework for long-term conditions. London: British Society of Rehabilitation Medicine. 2009.
  16. Turner-Stoke L. Specialist neuro-rehabilitation services: providing for patients with complex rehabilitation needs (SSND). Available from: https://www.bsrm.org.uk/downloads/specialised-neurorehabilitation-service-standards--7-30-4-2015-forweb.pdf (accessed 15 September 2019)